WILLIAM DONALD SCHAEFER, Governor

BY repealing and reenacting, with amendments,

Article - Health - General
Section 19-710(j)
Annotated Code of Maryland
(1987 Replacement Volume)

BY adding to

Article - Health - General

Section 19-1301     through 19-1315 19-1314, inclusive, to be

under the   new subtitle "Subtitle 13. Private Review
Agents"

Annotated Code of Maryland

(1987 Replacement Volume)

SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF
MARYLAND, That the Laws of Maryland read as follows:

Article 48A - Insurance Code

354HH.

(A)  EACH NONPROFIT HEALTH SERVICE PLAN PROPOSING TO ISSUE
OR DELIVER A HEALTH INSURANCE POLICY OR CONTRACT OR TO ADMINISTER
A HEALTH BENEFIT PROGRAM WHICH PROVIDES FOR THE COVERAGE OF
HOSPITAL BENEFITS AND THE UTILIZATION REVIEW OF THOSE BENEFITS
SHALL: MEET THE REQUIREMENTS OF TITLE 19, SUBTITLE 13 OF THE
HEALTH - GENERAL ARTICLE.

(1)  HAVE A CERTIFICATE IN ACCORDANCE WITH TITLE 19,
SUBTITLE 13 OF THE HEALTH - GENERAL ARTICLE;

(2)  CONTRACT WITH A PRIVATE REVIEW AGENT THAT HAS A
CERTIFICATE IN ACCORDANCE WITH TITLE 19, SUBTITLE 13 OF THE
HEALTH - GENERAL ARTICLE; OR

(3)  CONTRACT WITH OR DELEGATE TO A HOSPITAL
UTILIZATION REVIEW PROGRAM APPROVED UNDER § 19-319(D) OF THE
HEALTH - GENERAL ARTICLE.

(B)  NOTWITHSTANDING ANY OTHER PROVISION OF THIS ARTICLE,
FOR CLAIMS WHERE THE MEDICAL NECESSITY OF THE PROVISION OF A
COVERED BENEFIT IS DISPUTED, A NONPROFIT HEALTH SERVICE PLAN THAT
DOES NOT MEET THE REQUIREMENTS OF SUBSECTION (A) OF THIS SECTION
SHALL PAY ANY PERSON OR HOSPITAL ENTITLED TO REIMBURSEMENT UNDER
THE POLICY, CONTRACT, OR CERTIFICATE IN ACCORDANCE WITH THE
DETERMINATION OF MEDICAL NECESSITY BY THE HOSPITAL UTILIZATION
REVIEW PROGRAM APPROVED UNDER TITLE 19, SUBTITLE 13 OF THE HEALTH
- GENERAL ARTICLE.

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